Monday, July 26, 2004

Shameful liars, Part 2

I had the pleasure this weekend of talking some health care policy with a real, live doctor.  Our families were camping in the incomparable Waterton Lakes National Park (nicer than Banff, one-tenth the crowd), and the campfire chat was very educational.

One of the biggest issues on the table when debating health care reform is how to reduce demand, or at least slow down the increases to a manageable rate.  Most of the discussion rightly tends to focus on patient demand - how do we reduce the public's demand for a free service?  Can we introduce deductibles or co-payments without compromising the access of the needy to medically necessary services?

Generally overlooked, however, is the demand placed on the system directly by doctors, in the form of referrals to specialists, MRIs and CTs, etcetera.  We tend to gloss over this because we are taught to assume that doctors are, to be overly general, always right.  If they order an MRI for a patient, it must be because they need it.  If they schedule someone for back surgery, it must be because it will improve that patient's quality of life.

Talking with my doctor friend, however, this is simply not the case.  He was not telling me that doctors are blatantly wasteful, or pander pointlessly to their patients; rather, that there is insufficient disincentive for doctors to forego patient treatment options which, in their best judgement, are likely a waste of time, or at least much more costly than the likely benefit.

Bear with me briefly while I draw a parallel with engineering.  Engineers, like doctors, are professionals in the legal sense of the word in Canada.  Along with lawyers and accountants, they have self-governing bodies, where standards are set and enforced by their peers.

A structural engineer must design buildings so that, first of all, they don't fall down.  They should also last quite a while, and accommodate whatever demands will be placed on the building (roof loads, etc.).  The engineer must take personal responsibility for the design of a building's structure - there are no laws per se governing structures, as each one serves a unique purpose, on varying soil conditions, in different climates, etc.  And if a building design does not bear the seal of a professional structural engineer, it cannot get built - period.

If the structural engineering world operated on these bases alone, there's not much doubt that all buildings would be earthquake and bomb-proof, and built to last 500 years.  Much fewer buildings would go up, as they would be so expensive.  High-rises might not even exist.

This is obviously not the case, and the reason is that there is economic pressure on structural engineers to design buildings which are suitably safe and sturdy, while also being affordable to construct.  A structural engineer in Alberta who is unwilling to sign off on designs unless they will withstand an 8.5 earthquake will soon find himself out of clients and out of work.  He is forced, by the nature of his business, to acknowledge economic reality, while still being vigilant in his concern for public safety.

The point I am very slowly getting at is this:  if doctors are not required, by the nature of the system, to consider the costs of their decisions on the system, then they won't, or at least not very well.  At the same time, it is not necessarily true that if they do have to consider costs as part of their business, that patient care will be unduly compromised.

There is this notion out there, which the Canadian Medical Association is happy to play along with, that if doctors are forced to be accountable for the costs of their patients' treatment, health care will suffer enormously.  To use one example, if doctors (or health "regions") were compensated per patient rather than per service, we're told that bean-counters would wield the final word on proper patient care, and we'd be overrun with heartless medical practitioners who make Dr. Nick Riviera look like Albert Schweitzer.

My response is this:  when is the last time you heard about a building falling over because a structural engineer whored his principles for a few bucks?  Engineers are, on the whole, highly educated and dedicated people who are capable of weighing  costs against benefits, and distinguishing between right and wrong.  To suggest that doctors are less so insults them.

And if Dr. Monger or any other MD thinks I'm full of crap, I would love to hear why.

UPDATE (JULY 27th):  The Monger rejoins as do I.


At 9:08 p.m., Blogger The Monger said...

This is worth a sensible response--which I can't give right now because I'm getting my kidlets out of the tub.
I'll put a real answer on my blog, The Monger.


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